7 January 2019

End in sight for the sight test?

Over the last few decades, the care that optometrists offer goes well beyond a standard sight test. Clinical Adviser, Daniel Hardiman McCartney FCOptom, discusses whether this could mean the end of the sight test as we know it.

The sight test has been the optometrist’s staple product for decades. It is defined in the Opticians Act and, although when doing so we have to detect signs of abnormality, the purpose of the sight test is simply to ascertain whether or not the patient needs a prescription for spectacles. Yet as optometry has developed over the last thirty years, the care that we can offer now goes well beyond what is defined in a sight test, and moreover increasing numbers of those seeking our services do not require the testing of their sight. It may be red eye, dry eye or recent onset floaters, each requiring a different battery of tests and not the need for a refraction. 

I have spoken to some optometrists who are apprehensive about providing standalone assessments and they are surprised to learn that insisting on providing a sight test is not only unethical but may result in a review from the NHS counter fraud team. We have a duty to only perform a sight test when it is clinically indicated. In the case of the NHS, the GOS contract regulations in England, Wales, and Northern Ireland require that the contractor ‘satisfy itself that the testing of sight is necessary’ in order to proceed with a GOS funded test. This means that there must be a potential refractive cause to a person’s problems. Furthermore, using a sight test to examine a person presenting with a non-refractive complaint, not only subjects a person to a refraction they don’t need, and takes up clinical time better used for other investigations, it ties the practitioner to be subject to the regulatory requirements of the sight test. 

So what are the alternatives? Increasing numbers of practitioners are offering a menu of assessments, ones that can be triaged and can ensure the examination really is focused on the concerns of patients’ needs and an assessment without the constraints of the sight testing regulations. The benefit of offering a specialist assessment is that it can be just that! For example red eye, you can use your professional judgement to determine which tests are necessary and have sufficient time to complete them, concentrating your skills and energy on solving your patient’s specific concerns. Where there is not an NHS service commissioned, a private MECS or red eye assessments are a way of meeting that need; you may choose to build the test around an NHS MECS protocol, but you don’t have to: you have professional freedom. There is somewhat of a careful balance to be made; you should include sufficient investigations to fulfil your clinical obligations and arrive at a robust differential diagnosis without superfluous tests.

What are the disadvantages?  Firstly, you need to ensure you make it very clear to the patient at the time of booking what type of assessment it is, how much it will cost and that it is not a sight test, nor a substitute for one. You may need to re-design the record card for supplementary assessments and you may wish to design a recommendation or ‘findings slip’ to give to the patient. Secondly communicating this to the public requires some thought, particularly those who have always been accustomed to NHS eye care. 

"I have spoken to some optometrists who are apprehensive about providing standalone assessments and they are surprised to learn that insisting on providing a sight test is not only unethical but may result in a review from the NHS counter fraud team."

What tests to include?  When offering private assessments, you can use your own professional discretion to tailor the test to your patients’ clinical needs. For a private red eye service you may choose to base the test around the current NHS model, or alternatively design a service specification from scratch with your fellow optometrists, so all the optometrists in the practice or group can complete a similar set of baseline tests for each type of supplementary assessment.  Although it is important not to complete superfluous tests, many practices decide to always include some key tests, typically VA and pinhole - these are always clinically useful. There is an interesting debate regarding whether posterior pole assessment should also be included at every supplementary test, prudent for detecting co-morbidly but in many situations superfluous, however, for many, it’s a moot point as it is often a requirement of an optometrist’s professional indemnity insurance. Once offering a supplementary service, training the whole team about the difference between a statutory sight test and a supplementary test can be a useful way to ensure correct triage and educate potential patients about the services available. Although private MECS, flashes and floaters and dry eye are the obvious examples, there is the potential for others, provided a refraction is not required and what is on offer is not a substitute for a sight test. You can align your practice to your local needs. 

Is the end in sight for the sight test? I would argue not, people will continue to need visual correction and that will be an ongoing core role of the optometrist; in addition, maintaining the link between refraction and ocular health assessment is important for avoiding preventable sight loss. However, despite visual correction being important, the advent of more advanced subjective auto-refraction, the possibility of deregulation and subsequent potential for online service all pose a constant threat.  Diversifying into supplementary assessments could be considered be a prudent way to futureproof your practice whilst also developing the role of the optometrist.  By offering a more creative menu of clinical services, be they commissioned or private, optometrists can deliver higher quality and more appropriate care to those who want it, without the restraints of the statutory sight test. This is a real opportunity for the profession. 

Here are some highlighted aspects of the College’s Guidance for Professional Practice that are especially relevant when offering supplementary tests: